Provider Demographics
NPI:1972117026
Name:CAMPBELL, CHARSETTA DENISE (APRN)
Entity type:Individual
Prefix:
First Name:CHARSETTA
Middle Name:DENISE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14406 EDINBURGH MOOR DR
Mailing Address - Street 2:
Mailing Address - City:WIMAUMA
Mailing Address - State:FL
Mailing Address - Zip Code:33598-6153
Mailing Address - Country:US
Mailing Address - Phone:813-508-0595
Mailing Address - Fax:
Practice Address - Street 1:5771 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3407
Practice Address - Country:US
Practice Address - Phone:727-523-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-06
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL109574500363L00000X
FLAPRN11009006363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109574500Medicaid